BLAKE ADAMS — Practice pitfalls: Minor mistakes in Medicare enrollment can lead to major consequences for health-care providers

For the vast majority of health-care providers in Mississippi, Medicare reimbursement is an essential component of any practitioner’s or institution’s revenue stream. But let’s face it — no one likes dealing with Medicare enrollment forms.

The byzantine paperwork and forms required to participate in the Medicare program (each identified by a jumble of letters and numbers such as the CMS-855A, CMS-855B, CMS-855I, CMS-855R, or CMS-588) are tedious to complete and lack clear instructions for many situations. Obtaining guidance from the Medicare Administrative Contractor, or “MAC” (the government contractor in charge of processing Medicare enrollment paperwork for your region), can be an exercise in frustration at times, to put it politely.

Medicare regulations require providers to maintain accurate enrollment records which disclose, among other things, the physical address(es) or “practice locations” where the provider furnishes health care services. Health-care organizations are required to make additional disclosures regarding ownership, management and other information. Providers and suppliers must promptly report any changes in their enrollment information, typically within either 30 days or 90 days depending on the type of event and the type of provider or supplier. The Centers for Medicare and Medicaid Services (“CMS”), the government agency responsible for administering the Medicare program, considers accurate enrollment information to be a key tool in its efforts to combat program-related fraud and abuse.

However, all too often — and understandably so — providers do not think about their Medicare enrollment paperwork past their initial enrollment in the Medicare program or when they receive a request from the MAC to revalidate their enrollment (i.e., complete the enrollment paperwork again to ensure the information is up to date). In my experience as a health-care attorney who regularly deals with provider enrollment issues, it is rare to find a provider enrollment record that is 100 percent accurate and up to date. Unfortunately, as more and more health-care providers are discovering, the failure to maintain an accurate Medicare enrollment record can have dire consequences for your practice.

Consider the following scenario: Dr. Smith is an anesthesiologist who provides services in a number of different local facilities but does not maintain his own offices. In his Medicare enrollment, he listed as his primary practice location the address of a UPS store where he maintained a secure box to receive correspondence. Sometime later, the MAC sends an inspector to the UPS store address listed in Dr. Smith’s enrollment record and, finding no operational medical practice at that address, promptly revokes Dr. Smith’s enrollment in the Medicare program. Compounding Dr. Smith’s woes, the MAC additionally barred him from re-enrolling in the Medicare program for two years. A simple paperwork mistake consisting of listing the wrong address on an enrollment form resulted in potentially devastating consequences to Dr. Smith’s practice.

Sadly, this is not a hypothetical case but actual facts from a recent decision by the Departmental Appeals Board, which upheld the physician’s revocation and subsequent two-year suspension from the Medicare program.

This case reflects the harsh consequences that can now result from relatively minor and innocuous inaccuracies in a provider’s enrollment information. While CMS and the MAC previously may have rescinded similar revocation actions after a provider timely submitted a satisfactory corrective action plan (CAP), recent regulatory changes have eliminated providers’ ability to file a CAP following a revocation because of a failure to timely report changes in enrollment information or a determination that a practice location is non-operational.

In CMS’ view, “providers and suppliers should not be exonerated from failing to fully comply with Medicare enrollment requirements simply by furnishing a CAP.” In the discussion accompanying this rule change, CMS reiterated that “revocations based on a failure to timely report a practice location change should not be retroactively corrected via CAP” and that ultimately “it is the provider or supplier’s responsibility … to report changes to CMS on a timely basis.”

Thus, once a provider has been determined to be non-compliant with Medicare reporting requirements and is facing a revocation action and multi-year enrollment suspension, there is little recourse to have the decision reversed. Although providers are provided appeal rights, these revocation decisions have been consistently upheld where CMS or the MAC has accurately determined that a provider or supplier failed to maintain accurate enrollment information.

As stated above, Medicare reimbursement is essential to the financial viability of the majority of health-care practitioners and organizations in Mississippi. In light of the severe consequences that can result from even innocent or trivial inaccuracies in an enrollment record, it is vital that providers and suppliers take a proactive approach to compliance with Medicare enrollment requirements. It is recommended that every provider or supplier should put in place policies and procedures to implement the following:

» at least one annual review of your information in the online Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to ensure the enrollment information is accurate and up to date; and

» timely, thorough and accurate responses to all inquiries or requests for information from the MAC or a CMS representative.

Key Takeaway

In the context of Medicare enrollment, providers would be wise to heed the old saying that “an ounce of prevention is worth a pound of cure.” By being proactive in ensuring compliance with Medicare enrollment requirements, providers and suppliers can minimize the chance of facing the potentially catastrophic reimbursement consequences that can result from even minor enrollment mistakes.

» Blake Adams is a health-care attorney who focuses on regulatory compliance. He works as an associate in Phelps Dunbar LLP’s Tupelo office.

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